Provider Demographics
NPI:1306112495
Name:GONSALVES, PERSIS (PT)
Entity type:Individual
Prefix:
First Name:PERSIS
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 RUTHELLEN RD
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-4017
Mailing Address - Country:US
Mailing Address - Phone:619-228-3885
Mailing Address - Fax:
Practice Address - Street 1:70 BOSTON RD
Practice Address - Street 2:APT D313
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3049
Practice Address - Country:US
Practice Address - Phone:619-228-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19644225100000X
MI5501015575225100000X
CA39725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist